Treat before hypotension occurs: avoiding hysterectomy for postpartum hemorrhage.(Obstetrics)

NEW YORK -- A sequence of mechanical, medical, and conservative approaches to postpartum hemorrhage can usually stop the bleeding without resorting to hysterectomy, Dr. George Saade said at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

Don't wait until a patient with postpartum hemorrhage is hypotensive or tachypneic before starting treatment, advised Dr. Saade, professor of obstetrics and gynecology at the University of Texas Medical Branch at Galveston.

The average amount of blood lost during a normal vaginal delivery is about 500 mL; for a cesarean section, about 1,000 mL; and for a cesarean hysterectomy, approximately 1,500 mL. Since a normal pregnant woman will increase her intravascular volume by a liter or more during pregnancy, she may bleed that entire amount--comprising about 15% of her total blood volume--with no clinical signs of hypotension, especially if she is lying supine.

Mechanical manipulation is the first step; it's important to use both hands in massaging the uterus to try to stop the bleeding.

If that doesn't work, move quickly to a uterotonic agent. Oxytocin is first line, at a dose of 10-40 U in 1 liter normal saline or lactated Ringer's solution. It can be given by IV, IM, or intramyometrial (IMM) routes, but always in a continuous infusion--never a bolus. Side effects include nausea, vomiting, and water intoxication.

Methylergonovine is the second uterotonic agent to try if oxytocin fails. Just one 0.2-mg dose is given either IM or IMM--but never IV--every 2-4 hours. Potential side effects include nausea, vomiting, and vasospasm. The drug, a powerful vasoconstrictor, is contraindicated in patients with hypertension or coronary insufficiency, and therefore cannot be used in cases of preeclampsia.

Moreover, it's essential to move on to something else if one dose of methylergonovine doesn't work, since it can't be given again for 2 hours, Dr. Saade noted.